Experiences of Parental Presence in the Induction of Anesthesia in a Canadian Tertiary Pediatric Hospital: A Cross-Sectional Study

Background Parental presence at induction of anesthesia remains controversial and has been reported to provide mixed results. As such, parental presence at induction of anesthesia is not practiced routinely everywhere. There are currently limited data describing the practice of parental presence at induction of anesthesia or the experiences and perceptions of parents in Canada. Objectives We sought to investigate (1) the frequency of parental presence at induction of anesthesia and (2) the experiences and perceptions of parents accompanying their child into the operating room compared to those who did not at a tertiary Canadian pediatric hospital. Methods Institutional quality improvement approval was obtained. This study was a cross-sectional survey. Parents waiting in the parent surgical waiting room during the procedure were invited to complete a web-based survey. Consent was implied via completing the survey. The cross-sectional survey elicited the prevalence of parental presence during induction of anesthesia as well as their experience and perceptions. We also investigated the parents’ preferences for preoperative education. Results Of the 448 parents approached, 403 completed the survey between May and June 2017. Sixty-eight (16.9% [13.4-20.9]) parents accompanied their child into the operating room (parental presence at induction of anesthesia), while 335/403 (83.1% [79.1-86.7]) did not (no-parental presence at induction of anesthesia). Reasons for not accompanying their child into the operating room included “not being aware they could” (158/335, 47.2% [41.9-52.5]), “I didn’t think my child needed me” (107/335, 31.9% [27.2-37.1]), “my child was coping well” (46/335, 13.4% [10.5-17.8]), and “I was anxious” (47/335, 14.0% [10.7-18.2]). Most of the parents in the parental presence at induction of anesthesia cohort (66/67, 98.5% [95.6-101.2]) reported that they believed their child benefited/would have benefited from their presence during induction of anesthesia compared to those in the no-parental presence at induction of anesthesia cohort (137/335, 40.9% [35.8-46.2]), P < 0.001. Overall, 51/335 (14.7%) parents in the no-parental presence at induction of anesthesia cohort and 3/67 (4.5%) of those in the parental presence at induction of anesthesia cohort felt that offering parental presence at induction of anesthesia should depend on factors including child’s age as well as the level of coping and anxiety. More patients in the no-parental presence at induction of anesthesia cohort felt that parental presence at induction of anesthesia should also depend on the child's age and whether the child was coping. Parents felt that face-to-face discussions with clinicians are most effective for discussing future parental presence at induction of anesthesia. Conclusions We have shown that most parents at our institution do not undergo parental presence at induction of anesthesia and are for the most part comfortable with their child going unaccompanied into the operating room. Administrators and clinicians seeking to implement parental presence policies should consider navigating parental presence at induction of anesthesia with evidence-based approaches tailored to each parent and their child.


Objectives
We sought to investigate (1) the frequency of parental presence at induction of anesthesia and (2) the experiences and perceptions of parents accompanying their child into the operating room compared to those who did not at a tertiary Canadian pediatric hospital.

Methods
Institutional quality improvement approval was obtained. This study was a cross-sectional survey. Parents waiting in the parent surgical waiting room during the procedure were invited to complete a web-based survey. Consent was implied via completing the survey. The cross-sectional survey elicited the prevalence of parental presence during induction of anesthesia as well as their experience and perceptions. We also investigated the parents' preferences for preoperative education.

Results
Of the 448 parents approached, 403 completed the survey between May and June 2017. Sixty-eight (16.9% [13.4-20.9]) parents accompanied their child into the operating room (parental presence at induction of anesthesia), while 335/403 (83.1% [79.1-86.7]) did not (no-parental presence at induction of anesthesia). Reasons for not accompanying their child into the operating room included "not being aware they could" (158/335, 47.2% [41.9-52.5]), "I didn't think my child needed me" (107/335, 31.9% [27.2-37.1]), "my child was coping well" (46/335, 13.4% [10.5-17.8]), and "I was anxious" (47/335, 14.0% [10.7-18.2]). Most of the parents in the parental presence at induction of anesthesia cohort (66/67, 98.5% [95. 6-101.2]) reported that they believed their child benefited/would have benefited from their presence during induction of anesthesia compared to those in the no-parental presence at induction of anesthesia cohort (137/335, 40.9% [35.8-46.2]), P < 0.001. Overall, 51/335 (14.7%) parents in the no-parental presence at induction of anesthesia cohort and 3/67 (4.5%) of those in the parental presence at induction of anesthesia cohort felt that offering parental presence at induction of anesthesia should depend on factors including child's age as well as the level of coping and anxiety. More patients in the no-parental presence at induction of anesthesia cohort felt that parental presence at induction of anesthesia should also depend on the child's age and whether the child was coping. Parents felt that face-to-face discussions with clinicians are most effective for discussing future parental presence at induction of anesthesia.

Conclusions
We have shown that most parents at our institution do not undergo parental presence at induction of anesthesia and are for the most part comfortable with their child going unaccompanied into the operating room. Administrators and clinicians seeking to implement parental presence policies should consider navigating parental presence at induction of anesthesia with evidence-based approaches tailored to each parent and their child. 1 1 1 1

Introduction
The preoperative experience can be fraught with anxiety and uncertainty for parents of pediatric surgical patients. Techniques available to the anesthesiologist to prevent and manage preoperative anxiety in children include premedication, distraction techniques (videos, games, bubbles, clowns, virtual, and immersive reality), child life specialists, and parental presence at induction of anesthesia (PPIA) [1][2][3][4][5][6][7][8]. The benefits of PPIA remain controversial, and PPIA is not a part of routine practice everywhere [4][5][6][7][8][9][10][11][12]. In the United States, 58% of anesthesiologists have reported allowing parental presence in less than 5% of their cases [13]. In contrast, in Great Britain, most respondents (84%) allowed parental presence in more than 75% of their cases [13]. Parents experiencing PPIA have reported it as traumatizing or distressing to witness, with variable feelings in parents who decided not to attend induction (no-PPIA) and mixed feelings in the interactions with the care teams along with positive feelings [9,14]. Currently, there are no data describing the prevalence of PPIA in Canada as well as the experiences and perceptions of parents who were present or not present during the induction of anesthesia of their child.
The objectives of our study were to investigate the prevalence of parental presence during induction of anesthesia and explore parents' experience and perceptions of PPIA at a Canadian pediatric tertiary-care academic hospital. We also compared parents' experiences and preferences for preoperative education on PPIA. The results of this survey will help inform policies guiding PPIA at our institution and may be relevant to other institutions.

Ethics and setting
The study received approval from the Hospital for Sick Children's Risk and Management Committee as a quality improvement initiative. The survey was administered on an iPad™ to parents after their child was taken to the operating room for elective surgery at a Canadian pediatric tertiary-care academic hospital [15]. Parents were approached by the research assistant and were invited to participate in the study. Completion of the survey implied consent.

Participants
The survey was presented to a convenience sample of parents and parents who were waiting in the surgical waiting room during the procedure. Participants were assured that their participation was voluntary, and the information they provided remained confidential with the results being reported aggregate. Completion of the survey was taken as consent. Parents who did not speak English and those who did not consent to complete the survey were excluded.

Survey design
Following a literature review of other similar surveys, we designed the survey and pretested it on volunteer parents [11,13,[16][17][18][19]. No significant changes were made after feedback from the parents. Following pretesting among the authors and a pilot among eight parents, the final survey tool was loaded onto an iPad™ for administering to parents between May and June 2017. The responses from the testing and the pilot phases were not included in the analysis.
The final survey instrument consisted of five demographic questions for all participants, which then branches based on whether the parent/caregiver was in the PPIA cohort or the no-PPIA cohort. Parents in the PPIA cohort responded to six questions specific to their PPIA experience, while parents who did not accompany their child responded to six questions tailored to their no-PPIA experience. The survey concluded with three questions common to both cohorts.

Sample size and sampling
Based on a target population of 14,000 anesthetics each year for surgery alone at our institution, we required a minimum of 384 respondents to achieve a 95% confidence level with a 5% error margin [20][21][22]. To minimize sampling bias, we used a stratified sampling approach. We recruited 15 patients each day from the parent surgical waiting area. The research assistant administering the survey had no knowledge of whether parents were in the PPIA or no-PPIA cohort. The patient waiting area is located on a different part of the operating room floor, across several doors and corridors, preventing the research assistant from seeing which parents had been in the operating room. When each parent entered the waiting area, the assistant tossed a coin with heads denoting that they can be approached to participate in the survey. Each parent who had heads in the coin toss was approached until 15 patients were recruited each day. We also recruited 10 parents in the morning, between 8.30 am and noon when more operating rooms were open, and five parents in the afternoon, between 1 pm and 3 pm. This allowed us to sample from a wide pool of parents. Each day, 40-50 parents entered the parent waiting area, and almost half of them were approached for the study. The data was collected over a four-week period.

Statistical analysis
Descriptive statistics were used to summarize the results. Categorical variables are presented as frequency and proportion (95% confidence intervals). Pearson's Chi-square test was used to assess the difference in perceptions between the two cohorts on three questions asking how they felt their child benefited/would have benefited from their presence, whether PPIA should be offered to all parents, and if they would want to be present in the operating room in the future. The statistical significances were defined as P-value ≤ 0.05 with a two-tailed test. The survey is reported according to the Checklist for Reporting Results of Internet E-Surveys (CHERRIES) [23]. Statistical analyses were performed using SAS software, version 9.4 (SAS Institute, Cary, North Carolina).

Demographics
A total of 448 parents/caregivers were approached, with 46 declining and 402 participating in the survey. The demographics of parents participating in the study are presented in Table 1

Experiences in the parental presence at induction of anesthesia cohort
Sixty-eight (16.9%, 13.4-20.9) parents accompanied their child into the operating room, PPIA cohort. The most common reason given by parents for accompanying the child into the room was "I wanted to" 50/67 (74.6% [63.1-83.5]) ( Table 2).

In the future, would you want to be present in the OR while one of your children went to sleep?
Definitely   [12.4]; "Type of surgery," n = 14; "Physician discretion," n = 3; "Whether my child needed me," n = 37. † † Respondents selecting it depends on entered free text with the themes "Age of child," n = 50 [12.4]; "Type of surgery," n = 33; "Physician discretion," n = 3; "Whether my child needed me," n = 13.      Table 7 shows the perceptions of the information that parents had accessed online prior to their PPIA.

For internet-based information, please indicate your perceptions of the information you found
Easy to find 30 [

Discussion
Our study shows that most of the parents at our institution do not accompany their children into the operating room and are comfortable and accepting of this. Parents with younger children and previous experience with PPIA more often accompanied their children into the operating room. Overall, parents preferred a face-to-face discussion regarding the advantages and disadvantages of PPIA and would consider their child's age and ability to cope as factors influencing PPIA.
The finding that most parents attending our institution do not accompany their children into the operating is not surprising. A historical survey from 1996 administered to members of the Society of Pediatric Anesthesiologists reported a low prevalence of PPIA across the United States. About 58% of anesthesiologists in that study reported allowing parental presence in less than 5% of their cases compared to more than 84% of respondents in Great Britain who allowed parental presence in more than 75% of their cases [13]. While no updated data have been reported from the United State or Great Britain, our study shows a higher rate of PPIA compared to the United States. More importantly, our study attempts to shed light on the reasons and perspectives of both PPIA and no-PPIA cohorts. An interesting reason for no-PPIA among parents in our study population is that they stated that "their child didn't need them" or "was coping well." This suggests that a good proportion of children attending our institution can cope well and may be well prepared for their procedure and anesthetic through mechanisms not assessed by this current survey. Parents in the no-PPIA cohort also reported that the child's age and ability to cope as well as the anesthesiologist's assessment of the child were factors in determining whether they should be present during the induction of anesthesia or not. While our study did not assess the child's or parent's anxiety levels, anesthesiologists in pediatric settings have been shown to be better than mothers and trainees in predicting the anxiety of children during induction of anesthesia [24].
While most parents in the no-PPIA group wished they could be present, they reported their experience as positive and were comfortable with not being present for PPIA. One in 10 parents in the no-PPIA cohort reported their own anxiety as the reason for not accompanying their child to the operation room. Other studies have reported some parents experiencing PPIA describing it as traumatizing or distressing to witness, feeling "your world is not my world" and have also experienced mixed feelings in the interactions with the care teams [9,10,14]. Clinicians and administrators may need to consider the unintended consequences arising from the policy that "mandates" PPIA and may not offer the appropriate preparation and support for PPIA. In addition, some parents or children may have no desire for PPIA as their child may be coping well or exercising their autonomy in medical-decision making with the parent's support [25][26][27][28].
As a result, clinicians and administrators will need to navigate and offer PPIA in a manner that acknowledges children who do not desire or require PPIA and parents who may want to give their child independence in the preoperative setting and during induction of anesthesia.
In our study, parents who accompanied their child into the PPIA were of younger age, had previous experience with PPIA, and reported the desire to do so in the future. Parents in the PPIA cohort also reported their presence as beneficial to the child. While our study did not assess either the parent's or the child's anxiety during anesthesia induction, studies have shown that in most cases, parental presence does not appear to affect either the parent's or the child's anxiety -premedicating children, toys, videos, and internet-based cognitive therapy; the presence of child life specialists or clowns are viable alternatives for reducing the child's anxiety [1,5,6,[29][30][31][32][33][34][35]. Several parents in the no-PPIA cohort believed that PPIA would have been beneficial for themselves and suggested that it be offered to all parents always, and they were less likely to consider the child's age or coping as a factor informing PPIA. This may be explained by the fact that parents in the PPIA group were of younger children who had not yet developed independence or autonomy with the healthcare system [25].
Our study also reports that parents prefer face-to-face discussions as the most effective way for discussing the potential for PPIA. Parents also preferred a discussion on the reasons why they may or may not accompany their child to the operating room. In contrast, a small proportion of parents felt online resources were effective for future PPIA encounters. However, those who had used online resources found them useful for this purpose. This finding is useful for administrators and clinicians who may be developing training materials for PPIA and will need to ensure these meet a variety of parental preferences for online or inperson information [22,[31][32][33][34][35][36][37][38][39][40][41][42][43][44][45].
There are several limitations to the study. We restricted our study to the English language, which may have reduced representation from parents among minority groups and immigrants. We hope to translate future surveys into languages spoken by our patient populations. Further, as this was out of the scope of this study, we did not collect data on the process used for offering PPIA to parents. The use of premedication and other non-pharmacological agents may have influenced the offering of PPIA. The COVID-19 pandemic may have changed attitudes and practices around parental presence during the induction of anesthesia. Our study occurred before COVID and may not have captured these changes as a result of temporary restrictions imposed on parental presence in critical care areas [46,47]. Finally, our study did not assess patient perspectives on PPIA or no-PPIA, nor did we assess the anxiety of the parent or child during the induction of anesthesia [48][49][50][51]. These data are important in acquiring information to help clinicians and administrators navigate the role of PPIA. Nevertheless, our study had an adequate sample size to generate responses that are statistically representative of our English language population.

Conclusions
We have shown that most parents at our institution do not undergo PPIA and are for the most part comfortable and accepting of this. Further studies seeking the child's perspective on PPIA are warranted. Administrators and clinicians seeking to implement parental presence policies should consider navigating this area with evidence-based approaches tailored to each parent and their child.

Additional Information Disclosures
Human subjects: Consent was obtained or waived by all participants in this study. Hospital for Sick Children Risk Management Committee issued approval N/A. Approval was granted by the Quality Improvement Committee of the Hospital for Sick Children Risk Management Committee. Animal subjects: All authors have confirmed that this study did not involve animal subjects or tissue.

Conflicts of interest:
In compliance with the ICMJE uniform disclosure form, all authors declare the following: Payment/services info: All authors have declared that no financial support was received from any organization for the submitted work. Financial relationships: All authors have declared that they have no financial relationships at present or within the previous three years with any organizations that might have an interest in the submitted work. Other relationships: All authors have declared that there are no other relationships or activities that could appear to have influenced the submitted work.